Can ‘robots’ write referrals and scripts, legally?

Robots writing referrals and scripts could be the tip of a technology iceberg that splits the GP profession in two

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The relaunch of Drsicknote as Qoctor has highlighted a potentially huge loophole in Medical Board of Australia regulations for telehealth, which would allow this group, and others, to write scripts and generate new and repeat specialist referral letters without any human oversight.

Qoctor relaunched last week with the promise of specialist referral letters for patients generated by a computer using a questionnaire and algorithms developed by the company’s doctors.

The group also plans to offer the same service for certain categories of prescriptions.

TMR can’t find a precedent for such an offering in Australia, which is effectively the first fully hands-off artificial intelligent healthcare delivery system under the management of GPs.

However there is a strong precedent in the financial services industry where lots of financial adviser groups now offer their clients ‘robot advice’, where clients simply answer a detailed questionairre and a computer calculates the investor’s ideal portfolio, via a series of algorthms.  ‘Robot advice’ is becoming huge in financial services as it is enabling thousands more Australians to access to high quality, cheap investment portfolio construction.

Reaction to ‘robot medicine’ is predominantly negative and has been swift.

“We don’t believe that this is a good model of care,” A spokesperson for the AMA told TMR.

“It fragments care, bypasses the usual GP, has no access to the patient’s full medical history, and there is no appropriate examination of the patient.

“We say they (teleconsults) should be used to complement face-to-face consultations, not replace them.”

When asked if there were any regulations that contemplated, or prevented, what Qoctor is doing, the AMA pointed us to the Medical Board of Australia.

The Board has not yet responded to questions on the possible loophole.

While the technology-based consultation guidelines on the Board’s website imply that a doctor is at the end of the line on a telehealth consult, or physically reviewing a consult, the guidelines do not specifically discount the idea of a “robot” consultation. There is nothing specifically requiring an actual doctor to review each consult. You can look at the guidelines yourself  HERE.

So any GP or practice can, on one interpretation of the guidelines, set up a computer-based algorithm and do all that is required to meet the guidelines.

It is apparent that Qoctor has arrived at this interpretation.

According to Dr Aifric Boylan, who is a full-time practising GP and a director of Qoctor: “In certain circumstances it just doesn’t make any difference if they [a patient] are physically in the surgery or talking to a doctor, or not.

“Some consults can be effectively and safely done this way, and if we as practising doctors don’t start taking advantage of this technology and its efficiencies, others, like corporates, will, and that will cause real issues.”

TMR understands that no other teleconsulting service issues scripts on an algorithm-only basis (i.e., without any doctor review, even of a patient-generated form).

Doctus, and Readycare, which were two of the original start-ups in this space, and which make much of their money issuing scripts for conditions which might be embarrassing for a patient to front up to their GP on, such as contraception or erectile dysfunction, at least have a doctor look at all online script requests.

Dr Boylan says that so long as the algorithm is well thought out and tested, and you restrict it to certain circumstances, it is safe, and that most objections aren’t taking into account the utility now offered by digital technology for GPs.

News of Qoctor’s plans has already generated quite a bit of condemnation from other GPs.

On the Australian Doctor website a story on the company’s plan had attracted 14 comments, all condemning the service.

“There is no ethics or safety here. I have no doubt the HIC will close this loophole quickly,”  one comment said.

“Quality medicine flushed down the toilet AGAIN! Poor medicine rewarded. I want to retire!” another said.

Qoctor might be the tip of a technology-induced change iceberg that is going to split the GP profession down the middle on the question of digital healthcare delivery.

Dr Nick Woods, a doctor who is now working with Microsoft in Australia on improving  healthcare delivery, via improved connectivity and the introduction of AI in certain environments, says technology isn’t a panacea for all the issues facing healthcare delivery.

“But there is certainly some issue with many doctors not understanding where it is usefully and effectively applied, and where it is not, because it is changing so fast,” he says.

“As an example, it is not well understood, even by some of our radiologists in training, that machine learning and AI applied to imaging is revolutionising the accuracy and efficiency of assessments, and can significantly improve delivery, especially in remote regions.”

But even Dr Woods expressed some surprise when asked about the idea of robot-generated scripts.

“Wow, and there’s no legal barriers preventing that?” he asked.